Clinical factors useful in predicting aortic valve structure in patients >40 years of age with isolated valvular aortic stenosis

doi:10.1016/0002-9149(93)90159-A

The American Journal of Cardiology

Volume 72, Issue 2, 15 July 1993, Pages 194-198

https://doi.org/10.1016/0002-9149(93)90159-A Get rights and content

Abstract

A number of reports have described the frequency of coronary arterial narrowing in patients with valvular aortic stenosis. No published reports have examined the structure of the stenotic aortic valve in adults and related the valve structure to variables, including coronary arterial narrowing, useful in predicting that structure. One hundred eighty-eight patients having aortic valve replacement for isolated valvular aortic stenosis were studied. All patients were >40 years of age at the time of aortic valve replacement, all had coronary angiograms preoperatively, and of 182 patients (97%) measurements of serum total cholesterol had been obtained and 184 (98%) had body mass index calculated. The structure of the operatively excised valve was classified as unicuspid or bicuspid (congenitally malformed), or tricuspid aortic valve. A logistic regression model was developed that found 4 factors (age, serum total cholesterol, angiographic coronary artery disease and body mass index) to be predictive of aortic valve structure: (1) Patients with at least 3 or all 4 factors high or present (i.e., age >65 years, serum total cholesterol >200 mg/dl, body mass index >29 kg/m² and coronary artery disease) had a low probability (10 to 29%) of having a congenitally malformed valve; (2) patients with at least 3 or all 4 factors low or absent (i.e., age <65 years, serum total cholesterol ≤200 mg/dl, body mass index ≤29 kg/m², and no coronary artery disease) had a high probability (72 to 90%) of having a congenitally malformed valve. Thus, the morphology of the operatively excised stenotic aortic valve can be predicted with knowledge of the age, serum total cholesterol, body mass index and coronary artery status of the patient.

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Cited by (54)

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La válvula aórtica bicúspide (VAB) es la malformación cardíaca congénita más frecuente. Se asocia a un mayor riesgo de complicaciones cardiovasculares, entre las que se incluye la endocarditis infecciosa (EI).
Estudio observacional, unicéntrico de cohorte, que incluye de forma prospectiva a todos los pacientes ingresados por EI entre 1996 y 2014. Se analizan datos epidemiológicos, clínicos, microbiológicos, ecocardiográficos, complicaciones durante la hospitalización, necesidad quirúrgica, mortalidad intrahospitalaria y seguimiento a un año. Se excluyen los casos con endocarditis sobre válvulas protésicas o en otras localizaciones, y aquellos de cuya válvula aórtica no se tienen datos certeros acerca de su morfología. Se ha realizado un análisis estadístico comparativo entre VAB y tricúspide (VAT).
De un total de 328 casos con EI, 118 (35,67%) fueron sobre válvula aórtica. Tenían VAB 18 (16,22%). Los casos con VAB eran más jóvenes que los portadores de VAT (51 ± 19,06 vs. 60,83 ± 15,73 años, p = 0,021) y tenían menos comorbilidad (índice de Charlson 0,67 ± 0,77 vs. 1,44 ± 1,64, p = 0,03). En el grupo con VAB observamos tendencia a EI causada por Staphylococcus spp. (38,9 vs. 21,5%, p = 0,137). Con diferencia estadística, hubo más complicaciones perivalvulares entre los casos con VAB (55,6% vs. 16,1%, p = 0,001) predominando los abscesos (38,9 vs. 16,1%, p = 0,047). Ser portador de VAB fue el único factor predictor de las mismas (OR 7,87, IC del 95%, 2,38-26,64, p = 0,001). Los pacientes con VAB se operaron más (83,3 vs. 44,1%, p = 0,004) y la mortalidad durante el ingreso hospitalario fue menor, aunque no alcanzó significación estadística (5,6 vs. 25,8%, p = 0,069). La supervivencia a un año fue significativamente superior en el grupo de VAB (93,8 vs 69,3%, p = 0,048).
Los pacientes con EI sobre VAB son jóvenes, con poca comorbilidad asociada. Tienen frecuentemente complicaciones perivalvulares por lo que requieren cirugía precoz. La mortalidad intrahospitalaria comparada con EI sobre VAT es menor y la supervivencia a un año es significativamente mayor.
Bicuspid aortic valve (BAV) is the most frequent congenital cardiac disease. It is associated to a higher risk of cardiovascular complications, including infective endocarditis (IE).
Retrospective, observational and single centre study that included all patients with IE diagnosed between 1996 and 2014. An analysis was made of the epidemiological, clinical, microbiological and echocardiographic data, complications during hospital admission, need for surgery, in-hospital mortality, and 1-year follow-up. Cases with endocarditis on prosthetic valves or other locations were excluded, as well as those for which the aortic valve morphology had not been accurately defined. A comparative statistical analysis was performed between BAV and tricuspid (TAV).
Of a total of 328 cases with IE, 118 (35.67%) were on aortic valve, with 18 (16.22%) of them being BAV. The BAV cases were younger than TAV (51 ± 19.06 vs. 60.83 ± 15.73 years, P=.021) and they had less comorbidity (Charlson 0.67 ± 0.77 vs. 1.44 ± 1.64, P=.03).). There was a higher tendency of Staphylococcal origin (38.9 vs. 21.5%, P=.137), and 55.6% showed peri-valvular complications (TAV 16.1%, P=.001), in particular, abscesses (38.9 vs.16.1%, P=.047). BAV was the only predictive factor of peri-valvular complications (OR 7.87, 95% CI; 2.38–26.64, P=.001). Patients with BAV had more surgery during their admission (83.3 vs. 44.1%, P=.004), had less in-hospital mortality, with no statistical significance (5.6 vs. 25.8%, P=.069), and 1-year survival was significantly superior (93.8 vs 69.3%, P=.048).
Patients with IE on BAV are young, with low comorbidity. They frequently present with peri-valvular complications and they often require early surgery. Compared to TAV cases, in-hospital mortality is lower and 1-year survival is significantly higher.
ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease
2008, Journal of the American College of Cardiology
Citation Excerpt :
Most patients older than 45 years have significant BAV calcification and/or thickening, which often relates to hemodynamic severity. The presence of risk factors, such as hyperlipidemia, appears to be associated with progression of BAV stenosis (328,329). Progressive AS is the most common complication of BAV, and many patients will require valve surgery or percutaneous valvuloplasty, with only one third or fewer remaining functionally normal by the fifth decade of life (330).
Clinical Outcome and Echocardiographic Predictors of Aortic Valve Replacement in Patients with Bicuspid Aortic Valve
2007, Journal of the American Society of Echocardiography
Clinical outcomes and echocardiographic parameters associated with aortic valve replacement (AVR) for bicuspid aortic valve are scarce.
We conducted retrospective analysis of 208 adults with bicuspid aortic valve referred for transthoracic echocardiograms.
The Kaplan-Meier survival free of death or need for cardiac surgery was 72% at 5 years. Cardiac surgery was performed in 19%, the majority (68%) for symptomatic aortic stenosis. Peak gradient 80 mm Hg or greater (hazard ratio 11.8, 95% confidence interval 3.7-37.8, P < .0001) and aortic valve area less than or equal to 0.75 cm² (hazard ratio 2.9, 95% confidence interval 1.0-8.5, P = .05) predicted the need for AVR. Patients with a large (54%) versus normal left ventricular outflow tract dimension underwent AVR for symptomatic aortic stenosis at a larger calculated aortic valve area (1.07 ± 0.21 vs 0.75 ± 0.18 cm², P < .0001) but at a similar peak gradient and velocity ratio (76 ± 19 vs 76 ± 22 mm Hg, P = not significant; 0.23 ± 0.06 vs 0.26 ± 0.12, P = not significant, respectively).
Clinical events are common among patients with bicuspid aortic valve. Peak gradient 80 mm Hg or more and aortic valve area less than or equal to 0.75 cm² predicts the need for AVR. Gradients and velocity ratio better reflect the hemodynamic burden of aortic stenosis in patients with a large left ventricular outflow tract.
Design and Baseline Characteristics of the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) Study
2007, American Journal of Cardiology
Aortic valve stenosis and atherosclerotic disease have several risk factors in common, in particular, hypercholesterolemia. Histologically, the diseased valves appear to have areas of inflammation much like atherosclerotic plaques. The effect of lipid-lowering therapy on the progression of aortic stenosis (AS) is unclear, and there are no randomized treatment trials evaluating cardiovascular morbidity and mortality in such patients. The Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) Study is a randomized, double-blind, placebo-controlled, multicenter study of a minimum 4 years’ duration investigating the effect of lipid lowering with ezetimibe/simvastatin 10/40 mg/day in patients with asymptomatic AS with peak transvalvular jet velocity 2.5 to 4.0 m/s. Primary efficacy variables include aortic valve surgery and ischemic vascular events, including cardiovascular mortality, and second, the effect on echocardiographically evaluated progression of AS. The SEAS Study randomly assigned 1,873 patients (age 68 ± 10 years, 39% women, mean transaortic maximum velocity 3.1 ± 0.5 m/s) from 173 sites. Other baseline characteristics were mean blood pressure of 145 ± 20/82 ± 10 mm Hg (51% hypertensive); 55% were current or previous smokers; and most were overweight (mean body mass index 26.9 kg/m²). At baseline, mean total cholesterol was 5.7 ± 1.0 mmol/L (222 mg/dl), low-density lipoprotein cholesterol was 3.6 ± 0.9 mmol/L (139 mg/dl), high-density lipoprotein cholesterol was 1.5 ± 0.4 mmol/L (58 mg/dl), and triglycerides were 1.4 ± 0.7 mmol/L (126 mg/dl). The SEAS Study is the largest randomized trial to date in patients with AS and will allow determination of the prognostic value of aggressive lipid lowering in such patients.
Degeneration of native and tissue prosthetic valve in aortic position: Do statins play an effective role in prevention?
2007, International Journal of Cardiology
Citation Excerpt :
Over the last decades, a growing understanding of the risk factors for calcific aortic stenosis and of its histologic characteristics have led to new insights into how it develops. Investigators have found histologic similarities between the lesion of aortic stenosis and atheromatous coronary artery disease [7,8] and have established an association between traditional atherosclerotic risk factors and the development of calcific aortic valve disease [3,9–16]. Actual data indicate aortic stenosis is an active disease with a distinctive histological appearance and variable disease progression, which suggests this disease may be amenable to medical therapy to prevent or slow down its progression.
Degenerative aortic valve stenosis is a common disease in western countries. When it becomes severe, it confers significant morbidity and mortality. Aortic stenosis has been recognized as a complex inflammatory and highly regulated process with histological and immunochemical similarities with the process of atherosclerosis. Hypertension, smoking and diabetes mellitus have consistently been linked to the development of aortic stenosis. Endothelial injury or other processes that contribute to coronary disease may play a role in calcific aortic stenosis. Several observational studies suggests that the key factors of aortic stenosis are lipoproteins and that medical therapies with cholesterol lowering drugs may retard its progression. Similarly, it has been suggested that the process of degeneration of the tissue heart valve has been associated with the same risk factors of atherosclerosis and shares many histological and molecular characteristics. Assuming all this concept, and evaluating the results of a retrospective study it has been suggested to use statin also as medical therapy able to prevent tissue valve degeneration. Randomized controlled clinical trials will be needed to demonstrate the role of lipid intervention to prevent the progression of aortic stenosis and the degeneration of tissue heart valves.
Risk Factors Associated With Reoperation and Mortality in 252 Patients After Aortic Valve Replacement for Congenitally Bicuspid Aortic Valve Disease
2007, Annals of Thoracic Surgery
We aimed to determine the risk factors associated with mortality in patients with congenitally bicuspid aortic valve disease and dilation (<5 cm) of the ascending aorta after aortic valve replacement.
We reviewed 252 patients with bicuspid aortic valve undergoing aortic valve replacement at our institution from 1971 through 2000. Patients undergoing concomitant replacement of the ascending aorta were excluded.
The average patient age was 61 ± 15 years; 66.3% were male, and 40.5% of patients had coronary artery disease. The ascending aorta was normal (<4.0 cm) in 60.3%, mildly dilated (4.0 to 4.4 cm) in 24.2%, and moderately dilated (4.5 to 4.9 cm) in 15.5% of patients. Patients with moderate aortic dilatation had significantly lower prevalence of coronary artery disease compared with patients with normal ascending aortas (20.5% and 45.4%; p = 0.006). Mean follow-up was 8.9 ± 6.3 years. Long-term survival was significantly different across the three groups (p = 0.004). The 5-, 10-, and 15-year estimates were 78%, 59%, and 37%, respectively, in the normal aorta group; 88%, 77%, and 46%, respectively, in the mild aortic dilation group; and 92%, 83%, and 70%, respectively, in the moderate aortic dilation group. No significant difference in cardiac death was found among the groups (p = 0.08). The significant predictors of survival using the Cox regression model were coronary artery disease, age, decade of surgery, and ejection fraction. Aortic dilation was not significant after adjusting for these other variables. At follow-up, 18 patients required reoperation, 17 for aortic valve prosthesis failure and 1 for ascending aorta aneurysm.
The present study highlights the important adverse effect of concomitant coronary artery disease, advanced age, earlier decade of surgery, and reduced left ventricular ejection fraction on survival after aortic valve replacement for bicuspid aortic valve in patients with no or mild and moderate (<5 cm) dilation of the ascending aorta.

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Clinical factors useful in predicting aortic valve structure in patients >40 years of age with isolated valvular aortic stenosis

Abstract

Am J Cardiol

Am J Med